Medicare

What’s Not Covered by Original Medicare?

Original Medicare doesn’t cover some services that Medicare beneficiaries might need or want, but there are other ways to obtain that coverage.

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A valuable source of health insurance for its 36.3 million members, Original Medicare offers coverage for a wide range of medically necessary services, but it does not cover every health cost. Some non-covered services include:

It is important to understand your Medicare coverage to avoid surprises in your health bill if you seek care not included in your Medicare benefits

What Does Original Medicare Not Cover?

Though Original Medicare provides coverage for many hospital and outpatient services, it is important to know what it does not cover. However, for some of these excluded services, you may find coverage elsewhere.

Prescription Drugs

Nearly 84% of 60 to 79-year-old Americans take one or more prescription drugs, but Original Medicare generally does not cover outpatient prescription drugs, such as the type you pick up in a pharmacy. Medications for treating high cholesterol, high blood pressure, and diabetes are some of the most commonly used by Medicare beneficiaries. These types of medications are not covered by Original Medicare, so you may need to pay for them out of pocket. 

In limited situations, Original Medicare may pay for prescriptions that beneficiaries pick up at a pharmacy. For example, it might cover immunosuppressive drugs for people who have received a Medicare-covered organ transplant. Original Medicare may also cover some oral drugs for cancer or End-Stage Renal Disease.

Original Medicare also offers coverage for certain prescription drugs administered by healthcare professionals, such as injectable and infused drugs. Covered drugs include, but are not limited to:

  • Injectable osteoporosis drugs
  • Injectable blood clotting factors
  • Intravenous immune globulin (IVIG)

How to Find Coverage

People with Original Medicare who want prescription drug coverage have two options: buying a Medicare drug plan (Medicare Part D) or switching to a Medicare Advantage plan (Medicare Part C). Both plans are offered by private companies but work differently.

Medicare Part D adds optional prescription drug coverage to Original Medicare. Costs and covered drugs can vary between plans and insurers. But while this coverage is optional, those who do not enroll in a Part D drug plan when first eligible may incur a late enrollment penalty if they change their mind and enroll later.

Medicare Advantage, or Part C, is an alternative to Original Medicare. These plans are required to cover the same Part A and Part B services as Original Medicare, but many offer additional benefits. In 2022, 89% of Medicare Advantage plans included prescription drug coverage.

Long-term or Nursing Home Care

Original Medicare generally does not cover the long-term care beneficiaries may need as they age. Those who need care in an assisted living facility or nursing home may be responsible for shouldering the entire cost out of pocket.

Today’s 65-year-olds have an estimated 70% chance of needing long-term care in the future. Much of the care provided in long-term care settings is custodial, such as help with bathing or using the bathroom. Medicare does not generally cover this type of non-medical care. As nursing home care is expensive, it is critical to plan for other coverage options outside of Medicare; assisted living care averaged $48,600 in 2019, while a private room in a nursing home costs twice as much.

Original Medicare may cover short-term stays in a nursing home if it is medically necessary to recover from a hospitalization. However, this coverage is capped at 100 days per benefit period.

How to Find Coverage

Medicare beneficiaries concerned about the cost of assisted living or nursing home care could consider a private long-term care insurance plan. These policies can help pay for custodial care. 

Other options include Medicaid or VA benefits. Medicaid, a public health insurance program for low-income Americans, funded 42.1% of the nation’s long-term care costs in 2020. Each state’s Medicaid program covers nursing home care, and some cover services in assisted living facilities.

The VA healthcare program may cover long-term care for Medicare beneficiaries who served in the military.

Dental Care

Original Medicare does not cover most dental procedures to prevent, diagnose, or treat oral health problems. However, it may cover certain procedures in limited situations. The program may pay for:

  • Dental exams performed during pre-surgery workups for kidney transplants or heart valve replacements
  • Tooth extractions before radiation treatment for jaw tumors
  • Dental care that is part of another Medicare-covered procedure, such as jaw reconstruction surgery

But Medicare does not cover common dental services, such as teeth cleanings, cavity fillings, and tooth extractions. Medicare also does not cover dental devices like dentures. Beneficiaries may be surprised by the cost of these uninsured services. As of 2020, the national average cost of teeth cleaning is nearly $98. Filling a cavity starts at around $146, while a full set of dentures comes in at nearly $3,480.

However, this may change in the future as Congress recently considered creating a Medicare dental benefit as part of the Build Back Better agenda. The Medicare Dental Benefit Act of 2021 proposed to expand Medicare coverage to include dental and oral health services but was ultimately left out of the bill. While this act did not succeed, Congress could revisit Medicare dental benefits in the future.

How to Find Coverage

People with Original Medicare could add dental coverage by purchasing a stand-alone dental insurance plan from a private insurer. Costs and covered dental services can vary between policies, and some insurers offer plans tailored to Medicare recipients. Coverage may be limited to in-network dentists.

Medicare Advantage plans generally offer some coverage for dental care, though covered services can vary. For example, some Medicare Advantage plans limit dental coverage to preventive services, such as cleanings, and leave members responsible for other dental costs.

Vision Care

Original Medicare does not cover routine vision care, like eye exams or eyeglasses, so beneficiaries may want to budget for these costs or look into vision coverage options. Original Medicare also does not cover eye surgery to correct nearsightedness or farsightedness because these procedures are considered cosmetic surgery. 

However, Original Medicare does offer coverage for certain medically necessary vision care services, including:

  • Annual diabetic retinopathy screening for people with diabetes
  • Annual glaucoma tests for people at high risk of the condition
  • Tests and treatments related to age-related macular degeneration​
  • Eyeglasses/contact lenses after a cataract surgery procedure that implants an artificial lens
  • Cataract surgery

How to Find Coverage

Medicare beneficiaries who want vision care coverage could consider a Medicare Advantage plan to help pay for routine eye exams, glasses, contact lenses, and more. In 2022, 98% of Medicare Advantage plans covered eye exams and/or eyeglasses. Some plans may also offer coverage for surgical vision correction. 

​Stand-alone vision plans offered by private insurance companies are another option. Vision coverage could help pay for services like eye exams and corrective lenses, though you may be limited to a network of participating eye care providers.

Hearing Aids

Hearing aids and the exams used to prescribe and fit them are excluded from Original Medicare. Hearing loss is common among older Americans. Nearly a quarter of 65-to-75-year-olds live with disabling hearing loss, and the rate is twice as high for those 75 and older. Beneficiaries who need hearing aids could pay anywhere from $1,000 to $4,000 for them out of pocket, depending on the model.

While Original Medicare does not cover the hearing exams used to prescribe hearing aids, it may cover other hearing tests. For instance, it may cover diagnostic hearing tests a doctor orders to see if a person needs treatment for a health problem, like dizziness. 

Original Medicare also offers coverage for certain prosthetic devices when ordered by a doctor. This could include devices surgically implanted to improve hearing, such as cochlear implants. 

How to Find Coverage

Original Medicare members who want coverage for hearing exams or hearing aids could look into Medicare Advantage plans. In 2022, 95% of these plans offered coverage for hearing exams and/or aids. 

Every Type of Foot Care

With a few exceptions, Original Medicare does not pay for routine foot care performed by podiatrists, or for supportive devices for the feet. However, the program does cover medically necessary treatment for foot conditions. 

Routine foot care includes services people generally do to keep their feet healthy, including trimming nails, removing corns and calluses, and applying lotions. Original Medicare does not cover these services unless a beneficiary has a health condition that increases their risk of foot problems, such as diabetes.

Original Medicare also generally does not cover supportive devices for the feet, such as orthopedic shoes and custom insoles. Those who want these devices may need to pay out of pocket. However, Medicare may pay for supportive devices in limited situations, including for diabetics who need therapeutic shoes and inserts.

Despite these exclusions, Original Medicare offers coverage for a number of foot-related services, including:

  • Treatment of warts on the feet
  • Treatment of toenail fungus
  • Treatment of foot deformities, such as hammer toe or bunions

How to Find Coverage

Medicare Advantage plans may offer supplemental podiatry services, such as routine foot care for people without underlying health conditions. Some plans may also cover shoe inserts. 

Massage Therapy or Acupuncture

Original Medicare generally does not cover alternative or complementary therapies, such as massage therapy or acupuncture. However, acupuncture treatments specifically for chronic lower back pain may be covered in some situations. Medicare defines chronic low back pain as pain without a known cause that lasts for 12 or more weeks. Eligible beneficiaries could receive 12 sessions in 90 days, plus another 8 sessions if their back pain improves. 

Medicare excludes coverage for massage therapy, even when a doctor recommends this treatment. Medicare beneficiaries who receive therapeutic massages for chronic pain or other health issues may need to pay for their sessions out of pocket. 

How to Find Coverage

Some Medicare Advantage plans cover alternative medicine as supplemental benefits. In 2022, 36% of individual Medicare Advantage plans included acupuncture coverage. Some plans may also cover therapeutic massage.

All Chiropractic Care

Original Medicare offers limited coverage for services provided by chiropractors. It may help pay for medically necessary spinal adjustments, but not other chiropractic care.

The sole chiropractic service covered by Medicare is a hands-on treatment used to correct a subluxation of the spine. Medicare beneficiaries who want other chiropractic adjustments would need to pay for those services out of pocket. Medicare also does not cover any tests and treatments ordered by chiropractors. This includes X-rays that diagnose subluxations and related services provided in chiropractic clinics, such as massage therapy.

How to Find Coverage

Some Medicare Advantage plans may offer coverage for routine chiropractic care, in addition to the spinal adjustments included in Original Medicare.

Its Own Deductibles and Copays

While Original Medicare helps make healthcare more affordable, beneficiaries are expected to pay a share of the cost of covered services. These out-of-pocket costs could include deductibles, coinsurance, and copayments.

A deductible is a set amount you are responsible for paying before Original Medicare begins covering services. Coinsurance and copayments are a portion of the cost of Medicare-covered services.

Medicare beneficiaries’ out-of-pocket costs can vary depending on the health services they need. In 2018, the average out-of-pocket spend for people in poor health was $2,971, while those in good health spent $1,956. 

How to Find Coverage

Medicare Supplement Insurance, also known as Medigap, is an optional policy that works with Original Medicare to help pay for some of Original Medicare’s “gaps” — including copays, coinsurance, and other out-of-pocket costs for Parts A and B. In many states, insurance companies are allowed to sell 10 standardized Medigap plans, though some states offer different options. Massachusetts, Minnesota, and Wisconsin residents have access to different Medigap policies.

Care Outside the U.S.

Medicare beneficiaries who enjoy traveling abroad should be aware that Original Medicare does not generally cover medical care provided outside the United States and its territories. If you experience a medical emergency outside of the country, you may be responsible for the entire cost of care.

Out-of-country medical is only covered by Medicare in limited situations. For example, Medicare might cover medically necessary care on a cruise ship, so long as the ship is in U.S. waters. It may also cover emergency services in Canada for people traveling between Alaska and another U.S. state.

How to Find Coverage

Original Medicare members who are planning a trip may choose to buy a travel medical insurance policy. These temporary policies may help pay for routine or emergency care that happens in foreign countries. Costs and covered services can vary between policies. In addition, some Medigap plans offer additional coverage for foreign emergency care services and supplies.

Some Medicare Advantage plans cover urgent and emergency care outside the United States. Note that foreign hospitals might not bill the plan directly, so travelers could need to pay the full cost of care before being reimbursed by their insurer.

Cosmetic Procedures

Medicare does not cover elective cosmetic surgery, so beneficiaries who want popular procedures like facelifts, Botox injections, and LASIK surgery can expect to pay for the entire cost out of pocket. However, medically necessary cosmetic procedures may be covered, such as reconstructive surgery after an accident.

Some surgeries typically considered elective cosmetic procedures could be used for medical reasons, and Medicare may cover them if your doctor gets prior authorization. Procedures in this category could include Botox injections used to treat muscle disorders, or rhinoplasties (nose jobs) used to treat breathing issues.

How to Find Coverage

Some Medicare Advantage plans may cover cosmetic procedures that Original Medicare does not. It is important to check your plan’s benefit descriptions for details about these procedures.

What Does Medicare Cover?

Broadly, Medicare covers a range of health services that are necessary to prevent, diagnose, and treat medical conditions. Medicare Parts A and B each cover a different set of services:

  • Part A (Hospital Insurance): Part A offers coverage for inpatient hospital care, short-term nursing home stays, hospice care, and home health care. This includes major surgeries, physical and occupational therapies necessary to regain basic skills after a major surgery or illness, and limited stays at skilled nursing facilities.
  • Part B (Medical Insurance): Part B covers a long list of health services, from doctor services and health screenings to outpatient surgeries and durable medical equipment. This includes preventative services such as annual physicals and vaccinations, lab work needed to screen or diagnose conditions, as well as routine doctor’s visits for ailments.